Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Wednesday, September 03, 2008

You are depressed, take a placebo, and feel better. Conventional wisdom in the psychiatric community would have your depression coming back shortly because we all know that a placebo can't make you feel better for very long. Right? Um, sorry to crash the party, but... no. A study from Arif Khan and colleagues in the August 2008 Journal of Psychiatric Research debunks this myth by putting together results from 8 antidepressant trials which examined what happened to study participants who (a) showed a response to treatment in the short-term and (b) continued to take either an antidepressant or placebo in the long-term. Of those who continued to take antidepressants, 93% maintained their improvement 4 weeks to over a year afterwards. So did 79% of participants who took a placebo. So yeah, people on drugs did a bit better, but about 4 in 5 people taking a freaking sugar pill were still doing well in the long-term. Anyone still want to seriously argue that the vast majority of the antidepressant effect is not the placebo effect?

The authors, who incidentally are not exactly in the Peter Breggin camp, opine that: "The widely held – and probably erroneous – belief that the placebo response in depression is short-lived appears to be based largely on intuition and perhaps wishful thinking." Ouch. Wishful thinking about psychiatric medications? Hmmm, that is giving me Effexor flashbacks for some reason...

So it comes back to what I have said for years, that physicians need to remember we accept the premise from least to most invasive in treatment interventions. So, therapy is the first line, and then medications, albeit the exceptions like psychosis and suicidal depressions as overt examples to consider meds early on; there are other interventions as well, but I defer to space limits.

Neuropsych15 -- great blog. You are an astute reader of research and I give you an 'A' for excellent use of sarcasm! The point of my mentioning Breggin was not to weigh in on him one way or the other, but to note that the researchers who conducted this meta-analysis are not people who are anti-drugs.

WD and Roy -- Very good point. It is both placebo/expectations and remission over time. When there is not a no-treatment control group, it is hard to know how much is placebo and how much is just depression running its natural course. However, the research that I am familiar with indicates that the placebo gives you more than a control group which receives no intervention.

Therapyfirst: Wait, and you're a psychiatrist?? You are one of a dying breed. Shouldn't it be Cymbalta first, followed by Seroquel augmentation, then maybe adding perhaps another med before even thinking about psychotherapy? :-)

A person believes that the pill they are taking is a drug that will make them "better," in some sense. So they make themselves better (I see no other way of putting it), presumably according to their own criteria for "betterness". What would happen if one upped the criteria for betterness, such that a person had higher aspirations for themselves?

[sigh] It's a branch of investigation that's unlikely to be explored, I suspect.

This sounds fine on paper, but let's not forget that psychiatrists make their money by diagnosing "mental diseases" that require a lifetime prescription of the latest pharmaceutical agents.

I also wonder if an active placebo was used or not. Psychotropics are fairly easy to distinguish from placebo . Just try withdrawing from placebo... The lack of an active comparator understates placebo and overstates drug efficacy in my experience.

In my opinion, treatment that seems to be effective and successful needs to have the initial premise on the patient's part that change is needed. Accepting that medication has a place in the process early on, isn't the patient agreeing to take a pill feeding that premise: I will try this medication to hope it will have an effect for the better. Whoa, then after I start taking this pill, I might be more amenable to the ideas and reflections by a therapist to look at my psychosocial stressors, to step back and reexamine problems in my upbringing, hell, I might have to accept the idea that I need to do something different!

So, did a pill do that in and of itself, or maybe, just maybe, for a sizeable amount of patients who pursue mental health care in a responsible and realistic manner, the combination of services, or this placebo effect, even with a true medication, created a response. You decide!

By the way, I NEVER sell a patient that there is a need for a medication for the rest of his/her life. That is a totally BS comment by my so called colleagues. But, if you treat a patient looking for the quick fix, that is the conclusion a patient will come to early on in treatment.

When will psychiatric critics realize that a sizeable part of the problem with this overmedication model has been created by patients looking for this quick fix bs. We may write the Rxs, but last I looked, a lot are quick to fill 'em and take 'em!

I still do not see the muzzle prints on patients' foreheads forcing them to swallow. Blinded trust in the physician, or blinded trust in this stupid mantra by this society. Again, you decide.

TherapyFirst, with all due respect it is psychiatry that is promoting the idea that patients have a chemical imbalance which requires medication - patients are just responding to what you guys are promoting. I did not go into a psychiatrist's office seeking meds. In fact, just the opposite. I was resistant to meds. Guess what I went home with? A prescription, followed by another prescription, followed by another prescription... I got worse & worse. I took myself off of all meds & stopped seeing the shrink. I found a good therapist & I'm now several years med free & a lot better off.

You're correct that no one forced me to swallow the meds, however I trusted my physician to tell me the truth. He told me I needed meds to correct the chemical imbalance in my brain. I believed him. He also told me that my situation was grave & I would most likely need ECT. Thank god I got out before that happened. How are patients suppose to know they're being told a bunch of bunk?

It concerns me to read comments like the ones on Last Psychiatrist because it seems like psychiatrists are saying, well we have no choice really because patients are demanding the quick fix. What happened to doing the right thing even when it's not popular? My regular physician is one who doesn't hand out scripts for antibiotics if they're not needed. What that says to me is that he has the guts to do the right thing even when his patients are demanding antibiotics they don't need. He probably has some who don't come back because of his policy, but I think the majority appeciate his integrity. I know I do.

Having read the above Anonymous's comments two separate times this afternoon, I can only say this as a clinical psychiatrist: I practice what my alias says, as I preach to patients they should be in therapy if not first, at least concurrently if on meds. It is not an exagerration that more than 65% of them show irritation, indignation, confusion, dismay, and disregard for this recommendation. I keep track of my prescribing habits and I do not give Rxs to about 10-15% of my evaluations in that first visit. I would say half of those who do not get Rxs who I expect to follow up do not return. So, to answer your comment/question of "we [psychiatrists]have no choice really because patients are demanding the quick fix", I can only speak for myself in saying that it is a shame that the majority of psychiatrists have failed to maintain the standard of treatment in maintaining an adamant stance to insist patients be in therapy, at least for the beginning few months of treatment. We all have to be a bit realistic about our careers/income/credibility among peers and the community, so to take an extreme stance and not write many, if any prescriptions when they are warranted is not just foolish, it smacks of malpractice/malfeasance.

You know what I don't get still, and I have been practicing for only 15 years now, is that psychiatrists who have been around for more than 25 years are Rx shills so easily. I've been dismissed by peers and other MDs as idealistic and out of touch with the times, but I know and believe that therapy is the mainstay of the process, and how the hell so many of my peers just wimped out and let managed care dictate the treatment process for our profession is beyond criminal, it is abandonment, if not treason as a concept for our oath to the community.

Sorry to all of you who can't grasp the subjective, gray zone that is mental health. That is the beauty of it to those who are interested and invested to participate in the process. Whether or not it is paranoia or just pathetic reasoning, I feel there is an element of evil that has pervaded the field and allowed the degradation of psychiatry. How so many caring, invested, dedicated people sold out the society they committed to treat is beyond just a money issue to me.

anonymous, good points, but psych docs are put in a bit of a bind as well due to a ruling (forget the exact name but it starts with a t. tarloff?) that makes docs responsible for the subsequent behavior of patients whom they diagnose if they don't prescribe. fun all around.

My own experience of psychiatric drugs is that at best the positive effects last between 3 -6 months...at worst the negative effects kick in at day 1 and far outweigh any positive effects.

Having succumbed (through sheer desperation)a few months back to the belief that maybe trying one more lot of meds would help I can now report that what they did was sweet fanny adams. On the plus side I didn't get a variety of debilitating side effects.

My view of meds is that the placebo affect is alive and kicking under the guise of 'hope above reality'.

My father, bless his poor battered heart, is on a combination of strong psych meds and all they do is zonk him out. Which, in his words, "Is better than having the nasty thoughts". Bit of crap price to pay though..I think!!!!!

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I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...